Ischaemic Heart Disease for the
GP
Chris Tracey
GPVTS
What is Ischaemic Heart Disease?
• Artherosclerotic build-up
• Preventing perfusion to myocardium
• Spectrum....
Ischaemic Spectrum
Epidemiology
• Cardiovascular disease deaths 240,000 (2004)
• IHD deaths 117,000 (2004)
• Mortality decreasing
• Incidence stable
• Cost £1.7 billion in healthcare alone
Risk Factors
• Split into Modifiable and Non-Modifiable
Non-Modifiable
• Increasing age
• Male Gender
• Family Hx
• Ethnic Origin
Modifiable
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Smoking
Hypertension
Dyslipidemia
Diabetes Mellitus
Obesity
High Calorie Diet
Physical Activity
Why is this important?
• Risk Stratification
• Primary (and Secondary) Prevention
Risk Stratification
• Identifies risks
• Important as IHD risks are SYNERGISTIC
Risk Stratification
• Calculates ABSOLUTE risk of CVD event in 10
years
1)
2)
3)
4)
5)
Age
Sex
Cholesterol
BP
Smoking
What is “high risk”?
What is “high risk”?
• A >20% risk stratification
• i.e. Why statin therapy commenced at 20%
risk
• ?Possibility of commencing “medium” risk?
Artherosclerotic Plaques
• From 3rd decade – athroma build up – Angina
• From 4th decade – athroma plaque pathology
– ACS
Triad of IHD
Symptoms
ECG Changes
Cardiac Markers
Symptoms
• Again spectrum of symptoms – dependent on
ischaemic pathology and severity
Exertional Angina  STEMI
ECG Ischaemic Changes
• Can IHD be investigated by performing a 12lead ECG in a GP practice?
• Is a normal ECG at rest diagnostic of a nonischaemic pathology?
ECG Ischaemia
• 12-Lead ECG *During* acute event
Inducible Ischaemia
1) Exercise ECG
2) Stress ECG/Echo
3) Myocardial Perfusion Scanning
Cardiac Markers
• Should a GP request cardiac markers?
Cardiac Markers - Spectrum
Chest Pain Clinic
• Rapid Access Chest Pain Clinic
• Part of “National Service Framework”
• Nurse Led
• Risk Stratification
• Perform Inducible Ischaemic Testing
• At end of clinic appt – cardiac cause ruled out
• OR begin path of treatment and revasculariation
Coronary Angiography
Coronary Angiography
• Elective, Semi-Elective or Emergency
• Excellent as Diagnostic AND Therapeutic
• Whats involved?
Coronary Angiography – for the GP
• “I had an angiogram and a stent last week and
now I just feel awful......”
Coronary Angiography – for the GP
• “I had an angiogram and a stent last week and
now I just feel awful......”
• “I’m not eating and drinking, and I’m not
passing much urine.......”
Coronary Angiography – for the GP
• Renal Failure – incidence aprox 10%
• High risk group
• Contrast Load & dehydration
• Check the U&Es if asked to on the TTO!
Coronary Angiography – for the GP
• “I had an angiogram last week and now I’ve
got this bruise in my groin......”
• Haematoma OR Pseudoaneurysm
• Difficult to diagnose clinically
• Refer for Cardiology Tertiary Centre
• Urgent Ultrasound diagnostic
If the risk stratification and
modification wasn’t enough.....
Acute Coronary Syndromes
ACS - Spectrum
NSTEMI  STEMI
• Diagnosed on Triad.....
• Managed the same?
• NSTEMI – ACS protocol and semi-urgent angio
+/- re-vascularisation
• STEMI – Immediate angio +/- revascularisation
Revascularisation
• Angioplasty
• Stent Insertion
• CABG
Post Discharge of ACS
Medications
1) Aspirin 75mg OD
2) Clopidogrel 75mg OD
3) Atorvastatin 40/80mg ON
4) Ramipril – titrated to max dose
5) Bisoprolol – titrated to max dose
6) PPI cover – Ranitidine vs. Lansoprazole
Ideal Medications
1) Aspirin 75mg OD
2) Clopidogrel 75mg OD
3) Atorvastatin 80mg ON
4) Ramipiril 10mg ON
5) Bisoprolol 10mg OD
6) Lansoprazole 30mg OD
The Echo
• Guidelines state all patients should have an
echo post ACS
• Reality?
• Important to assess LV function post-infarct
• Guides:
1) Management
2) DVLA guidelines
DVLA guidelines
• If untreated ACS (i.e. No stent)
• 4 weeks
• If treated ACS (i.e. Stented)
• 1 week
• No driving for 28 days if LVEF <40%
• 6 weeks for all HGV!
Cardiac Rehab
• 8-12 week programme
• Statistically significant at reducing risk factors at 1
year follow-up
• 20% dec in re-infarction at 1 year
• GP refers if attended Tertiary Cardiology Centre
STEMIs..... Which territory?
Which vessel?
ACS on ECGs is EASY
Inferior  Anterior  Lateral
Territory - Vessel
• Inferior = Right Coronary Artery
• Anterior = Left Anterior Descending
• Lateral = Left Circumflex
Which territory? Which Vessel?
Which territory? Which Vessel?
Which territory? Which vessel?
STEMIs Overview
• Inferior – arrhythmias acutely
- well long term
• Anterior – LV failure acute and long term
• Lateral – generally do well